NHS Digital Type 1 Opt Out / Opt in

If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice OR if you want to opt back in your can also use this form

Last Updated: 05/07/2021

NHS Digital Type 1 Opt Out

The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research. If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice.

Title *

Mrs

Miss

Other

Forename *

Surname *

Address *

Phone Number *

Details of parent or legal guardian

If you are filling in this form on behalf of a dependent e.g. a child, the GP practice will first check that you have the authority to do so. Please complete the details below:

Name

Address

Relationship to the Patient

YOUR DECISION

Opt In OR Out

Opt-out OR Opt- in

I do NOT allow my identifiable patient data (OR that of the person named in this form) to be shared outside of the GP practice for purposes except my own care.

I DO allow my identifiable patient data (OR that of the person named in this form) to be shared outside of the GP practice for purposes beyond my own care.

Your declaration

I confirm that: the information I have given in this form is correct OR that I am the parent or legal guardian of the dependent person I am making a choice for set out above

Please type name to confirm

PRACTICE USE ONLY

Opt – Out - Dissent code: 9Nu0 (827241000000103 |Dissent from secondary use of general practitioner patient identifiable data (finding)|)

PRACTICE USE ONLY

Opt – In - Dissent withdrawal code: 9Nu1 (827261000000102 |Dissent withdrawn for secondary use of general practitioner patient identifiable data (finding)|)

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NHS Digital Type 1 Opt Out / Opt in

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